Wirral University Teaching Hospital NHS Foundation Trust

Clinical challenge
To increase the proportion of patients who receive a six month review.

Solution
The stroke data co-ordinator compiles a database for all patients who are referred to the Stroke team, which can be crosschecked against SSNAP stroke patients. On discharge, all stroke patients receive 6 week follow-up appointment at the hospital with either a Stroke doctor or Stroke Specialist Nurse (SNS) and a further 6 months post stroke appointment is made after this initial review.

In addition, the data co-ordinator reviews patients approaching SSNAP’s 8 month “breach” for follow-up. Using the Trust’s operating system (Cerner) and SSNAP’s “Unlocked Records” report, she identifies patients with a forthcoming outpatient appointment; those who are deceased or have moved out of the area; those who failed to attend appointments and any who have been transferred elsewhere are requested back to enable 6 month data to be entered.

The SNS’s receive a monthly report and patients who are too unwell or frail to re-attend outpatients will be reviewed by telephone or by a home-visit. A recent development has been the SNS’s telephone call time to be entered onto the Trust’s electronic patient record (EPR) as clinical time and any correspondence resulting from this is on the EPR and a virtual review tariff is claimed.

Impact
The result is 100% completion of 6 month assessment ensuring that every stroke patient within the service has the opportunity to access on-going support from the stroke team and address any post discharge issues. Patients and families now have a choice in how they receive their review and this has been positively welcomed. A recent post discharge patient and carer questionnaire suggested a very high level of satisfaction with the care and post discharge support received.